Many nursing home residents with advanced dementia receive suboptimal care at the end-of-life (EOL). The Physician Orders for Life-Sustaining Treatment (POLST) paradigm is a strategy to improve the quality of EOL care. It is designed to promote goals-of-care discussions among healthcare providers (HCPs), patients, and surrogate decision makers (SDMs) and to ensure that care decisions are documented and honored by HCPs across care settings. Its use is widespread and growing across the United States. Despite extensive evidence of positive outcomes related to POLST use, little is known about SDMs' engagement and experiences during POLST discussions for nursing home residents with advanced dementia. Understanding SDMs' needs during the POLST process is essential to facilitate high quality treatment decisions, enhance SDMs' satisfaction with their decisions, and promote patient/family-centered care. Therefore, specific aims of the proposed study are to: 1) describe SDMs' roles and specific tasks as they participate in POLST discussions and 2) describe SDMs' experiences of engaging in these discussions, including their perceptions of facilitators and challenges to making treatment decisions. A qualitative descriptive design consisting of participant observation during HCP- SDM POLST discussions and post-discussion interviews with SDMs will be employed. The proposed study will examine 12-15 HCP-SDM POLST discussions and post-discussion interviews with SDMs. Data collection and analysis will be guided by Torke et al's Model of Communication and Surrogate Decision Making. Directed content analysis will be used to examine the data. Scientific rigor will be ensured by expert/peer debriefing, member checks, triangulation, and audit/decision trail. Study findings will provide an emic perspective of the SDMs' experiences during and following POLST discussions. Findings will also provide a foundation for the future development and testing of specific strategies to improve the quality and outcomes of POLST discussions, particularly for persons with advanced dementia and their families. The goals of this study are well aligned with NINR's priority to develop strategies to improve communication between family members and healthcare providers regarding palliative and EOL care.